Health inspection·December 4, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a care plan to meet the needs for one of three sampled residents (Resident 1). Resident 1 was assessed at risk for elopement (leaving an institution without notice or permission) and required a wander guard (a system used to alarm staff of a potential elopement of a resident) to be applied. This deficient practice resulted a wander guard not being applied to Resident 1 and Resident 1 eloping from the facility on 11/26/2023. This deficient practice had the potential for Resident 1 to sustain an injury and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/10/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. During a review of Resident 1's Elopement Risk Evaluation, dated 11/6/2023, the Elopement Risk Evaluation indicated Resident 1 was ambulatory with an assisted device, had intermittent (on again, off again) confusion, received medications that increase restlessness and agitation and had a history of elopement for the last six months. The Elopement Risk Evaluation indicated Resident 1 scored an 18 for elopement (A score of 10 or higher is considered at risk for elopement/wandering). The Elopement Risk Evaluation indicated to apply a wander guard to Resident 1. During a review of Resident 1's Change of Condition (COC) dated 11/26/2023 and timed at 8:30 a.m., the COC indicated Resident 1 was missing at 8:30 a.m., a search for Resident 1 was initiated and Resident 1 was found next door to the facility at a local business. During a review of the Care Plan section of Resident 1's clinical records, the Care Plan section indicated there was no care plan developed related to Resident 1's at risk assessment for elopement. During a concurrent interview and record review on 12/4/2023 at 10:07 a.m., Resident 1's MDS and Elopement risk evaluation was reviewed with the MDS nurse confirmed and stated Resident 1 was assessed Page 1 of 4 055457 055457 12/04/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as high risk for elopement and a care plan for exit seeking/wandering should have been created. The MDS stated the purpose of a care plan is to ensure residents' get the proper care and the necessary interventions are implemented. During an interview with the Director of Nursing (DON) on 12/4/2023 at 11:50 a.m., the DON stated that Resident 1 didn't have a care plan and Resident 1 was not receiving proper care regarding supervision and elopement. During a review of the facility's Policy and Procedure (P/P) titled Care Plans, Comprehensive Person-Centered,revised 3/2023, the P/P indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 055457 Page 2 of 4 055457 12/04/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 1), who was assessed as at risk for elopement (leaving an institution without notice or permission) with a wander guard, per their elopement Risk Evaluation. This deficient practice resulted in Resident 1 eloping from the facility on 11/26/2023, without a wander guard in place. This deficient practice had the potential for Resident 1 to sustain an injury and/or death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/10/2023, the MDS indicated Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 used a walker during ambulation. During a review of Resident 1's Elopement Risk Evaluation, dated 11/6/2023, the Elopement Risk Evaluation indicated Resident 1 was ambulatory with an assisted device, had intermittent (on again, off again) confusion, received medications that increased restlessness and agitation and had a history of elopement during the last six months. The Elopement Risk Evaluation indicated Resident 1 scored an 18 for elopement (a score of 10 or higher is considered at risk for elopement/wandering). The Elopement Risk Evaluation indicated to apply a wander guard (a system used to alarm staff of a potential elopement of a resident) to Resident 1. During a review of Resident 1's Change of Condition (COC) dated 11/26/2023 and timed at 8:30 a.m., the COC indicated Resident 1 was missing at 8:30 a.m., a search for Resident 1 was initiated and Resident 1 was found next door to the facility at a local business. During an interview on 12/4/2023 at 9:50 a.m., Licensed Vocational Nurse 1 (LVN 1) stated he last saw Resident 1 during rounds at 7 a.m., and certified nursing assistant (unknown) reported to him that Resident 1 was last seen between 7:30 a.m., and 8 a.m., when breakfast trays were passed out. LVN 1 stated at 8:30 a.m., when Resident 1 could not be found anywhere, an immediate search was initiated. LVN 1 stated Resident 1 was found next door to the facility at a local business unharmed. During a concurrent interview and record review with the Director of Nursing (DON) on 12/4/2023 at 11:50 a.m., Resident 1's Elopement Risk Evaluation dated 11/6/2023 was reviewed. The DON stated the Elopement Risk Evaluation indicated Resident 1 was assessed as at risk for elopement and that Resident 1 should have had a wander guard placed on her. The DON stated we were lucky to find her right away, she could have gotten hurt. During a review of the facility's Policy and Procedure (P/P) titled Wandering and Elopement, 055457 Page 3 of 4 055457 12/04/2023 Intercommunity Healthcare & Rehabilitation Center 12627 Studebaker Road Norwalk, CA 90650

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revised 3/2023, the P/P indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. During a review of the facility's P/P titled Safety and Supervision of Residents, revised 7/2017, the P/P indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents' assessed needs. The frequency and type of supervision varies per the needs of each resident. 055457 Page 4 of 4